ENHANCING MATERNAL AND CHILD HEALTH SERVICE COVERAGE ESTIMATES AND PROGRAM EVALUATION AT THE SUB-NATIONAL LEVEL THROUGH ROUTINE HEALTH INFORMATION SYSTEMS DATA ADJUSTMENT IN NIGERIA

Nigeria continues to face diverse challenges in maternal and child health (MCH). There is growing interest in health system strengthening programs in low- and middle-income countries to address the MCH challenges, but few evaluations have quantified their effectiveness due to lack of rigorous study designs and challenges in accessing timely and reliable data. The objectives of this dissertation were to assess the feasibility of using underexplored routine health information systems (RHIS) data for coverage estimates and program evaluation in three states in Nigeria (Ebonyi, Kebbi, and Zamfara). In Aim 1, RHIS data was used to estimate four or more antenatal care (ANC4) coverage and infant fever prevalence. I comprehensively assessed data quality of RHIS, evaluated the effectiveness of various adjustment methods for coverage and prevalence estimates, conducted sensitivity analysis, and triangulated different coverage and prevalence estimates with various population-based surveys in Nigeria. The adjusted ANC4 coverage using service-based denominators aligned more closely with population-based surveys estimates. Quarterly infant fever prevalence estimates showed strong seasonality and good alignments, with the adjusted infant fever prevalence using population-based denominators aligned most closely with survey estimates. In aim 2, I used quasi-experimental design with an interrupted time series analysis with 6- or 12- month seasonality to evaluate the impact of integrated (IHP) and vertical (PMI-S) programming on three child malaria cascade ratios: rapid diagnostic test (RDT) Testing Prevalence; RDT Positivity Prevalence; and Confirmed Case Treatment Prevalence. IHP in Kebbi and PMI-S in Zamfara were associated with significantly increased RDT testing and treatment prevalence, while results were more complex in Ebonyi due to the higher values of all outcomes at baseline in intervention facilities. State-level differences in program impact highlight that both integrated IHP program and disease-specific PMI-S program can be effective for malaria interventions, but their relative impact varies by context. The study filled research gaps by providing a replicable methodological framework that used RHIS data for sub-national coverage/prevalence estimates and program evaluation. Our findings with further validation can inform timely and evidence-based decision-making, reduce the malaria burden, inform resource allocation, strengthen health systems, increase service accessibility, inform health initiatives, and improve MCH outcomes.